Background Information Pertaining to the Forensic Investigation into the Death of Anna Nicole Smith - Joshua Perper, MD, LLB, MSc Chief Medical ...
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Background Information Pertaining
to the Forensic Investigation
into the Death of
Anna Nicole Smith
Joshua Perper, MD, LLB, MSc
Chief Medical Examiner
Broward County, Florida
March 2007
1Initial Information
• Anna Nicole Smith found unresponsive at
Seminole Hard Rock Hotel and Casino
• Possible “stomach flu” for several days
• Body transported to Memorial Regional Hospital
• Pronounced dead and Medical Examiner’s Office
notified at 2:49 PM February 8, 2007
2Medical Examiner Jurisdiction
• Dictated by Florida Statute
• 406.11 The medical examiner of the
district in which the death occurred . . .
shall determine the cause of death . . .
when any person dies:
9 suddenly, when in apparent good health
9 in suspicious or unusual circumstances
9 unattended by a practicing physician
3Medical Examiner’s Office
Immediate Response
• Dispatched Dr. Gertrude Juste, Associate Medical
Examiner, to the scenes (hotel and hospital)
• Many prescription drugs recovered in hotel room;
no illegal drugs
• Dr. Juste accompanied body from hospital to
morgue
• Activated high-profile security precautions with
Broward Sheriff’s Office
• Developed autopsy checklist
4Patient Received at M.E. Facility
• Brought in at 4:59 PM under routine protocol in
manner preserving dignity of the deceased
• Assembled Forensic Team
• Initial documentation started
• Brief external examination
9 No evidence of blunt force, sharp force,
gunshot wound, or asphyxiation
9 Samples taken for microbiology, toxicology,
serology, DNA, trace evidence
5Forensic Team
Dr. Joshua Perper
Chief Medical Examiner
Dr. Stephen Cina
Deputy Chief Medical Examiner
Dr. Gertrude Juste
Associate Medical Examiner
AUTOPSY CREW
Dr. Reinhard Motte
Associate Medical Examiner Dean Reynolds
Chief Autopsy Room Technician
Dr. Harold Schueler
Chief Toxicologist Irma Moten
Autopsy Room Technician
Edwina Johnson Joe Anderson
Chief Investigator Visual Imaging Technician
Wendy Crane James Fleurimond
Investigator Visual Imaging Technician
6Evening of February 8, 2007
• Body and tissue samples secured in
locked area of morgue
• Autopsy scheduled for next morning
approximately 9:30 AM
• Final autopsy checklist developed and reviewed
7Autopsy: February 9, 2007
• Forensic Team present
• Prosectors:
Dr. Joshua Perper and Dr. Gertrude Juste
• Autopsy commenced at 10:36 AM,
ended 6 hours later
8Autopsy: February 9, 2007 (Cont’d)
• Extensive sampling of tissues and body fluids
for toxicological analysis
• Additional samples for DNA
• Cultures of organs and internal body fluids
for evidence of infection
• Detailed examination of body cavities
and all organs
• Samples taken for microscopic evaluation
9Initial Autopsy Findings
•Gross examination*
• Subtle, mild discoloration of heart muscle
• Possible changes to intestinal lining
• Congestion with mild enlargement of liver
• Small amount of bloody fluid in the stomach
(commonly seen in terminal shock)
• Non-specific edema (water logging) of lungs
* Changes visible to the naked eye 10Microscopic Findings
• Heart: minimal, focal heart muscle scarring;
likely clinically insignificant
• Lungs: mild terminal aspiration; patchy edema
• Mild chronic duodenitis (minimal intestinal inflammation)
• Slightly increased number of acute inflammatory
cells in spleen (consistent with infection)
• Chronic inflammation of thyroid gland
(Hashimoto thyroiditis)
11Volunteering Medical Consultants
Dr. Stephen Nelson, neuropathologist and Chief Medical Examiner,
Polk County, Florida
Dr. Michael Bell, cardiopathologist and Chief Medical Examiner,
Palm Beach County, Florida
Dr. Azorides Morales, cardiopathologist and Chairman of Department
of Pathology, University of Miami
Dr. Gordon Dickinson, infectious disease specialist, Professor and Chief
of Department of Infectious Diseases, University of Miami
Dr. Margaret Gorensek, infectious disease specialist, Chief of
Department of Infectious Diseases, Cleveland Clinic, Florida
Dr. Michael Bayerl, hematopathology, Assistant Professor, Department
of Pathology, Milton S. Hershey Medical Center, Pennsylvania
12Evaluation by Consultants
• Two cardiopathologists examined
the heart in detail
No significant gross or microscopic abnormalities
other than minimal focal scarring in one of many
slides (deemed clinically insignificant; found in many
normal hearts if extensively sampled) and a tiny
focus of chronic inflammation on one slide of many
• Neuropathologist examined the brain and found
no obvious lesions to explain death
13Some of the Conditions
Excluded by Autopsy and Tests
• Pneumonia • Cirrhosis, fatty liver, hepatitis
• Pulmonary thromboembolism • Leukemia
• Asthma • Kidney infection
• Coronary artery disease • Renal changes compatible
Heart problems with diabetes or lupus
• Stroke • Pregnancy
• Cancer • Internal bleeding
• Large amounts of pills
in the stomach
14Investigation into
Circumstances of Death
• 12 individuals interviewed
(friends, physicians, witnesses)
• Bottles of medication from U.S.A. and Bahamas examined
• Dr. Gertrude Juste and investigator Wendy Crane traveled to
Bahamas to conduct additional interviews & review medical
records
• Review of Seminole Police Investigation file
• Forensic examination of two of Miss Smith’s laptop computers
• Developed detailed timeline leading up to death
15Social and Medical History
• Information obtained from witnesses
and public sources:
9 Chronic pain
9 Long term prescription drug use
9 Questionable “seizure” history
(possibly related to medications)
9 Fluctuating weight
9 Stressors: public scrutiny, protracted lawsuits
16More Recent Events
• Prescription drug use, including Methadone,
during recent pregnancy
• Birth of daughter, Dannielynn, September 2006
• Death of son, Daniel, 3 days later—emotionally
devastating, depression
• Near drowning episode in October 2006
associated with probable drug intoxication
resulting in pneumonia
17The Last Few Months
• Continued use of multiple prescription drugs
• Continued injections of various “longevity
medicines” and diet medications, including
Vitamin B12, Growth Hormone, Topamax, and
immunoglobulins
• Suicidal comments in short-term after son’s death
• Mood variable but improving
• Additional stressors: Paternity suit, suit regarding
ownership of residence in Bahamas, inheritance
suit re: husband’s estate 18The Final Week
• New stressor: Lawsuit filed against TrimSpa
• Ongoing paternity, estate, and residential lawsuits
• While in Bahamas, had injections into buttocks of
B12, Human Growth Hormone, or
immunoglobulins
• Planned trip from Bahamas to Fort Lauderdale on
Monday, February 5, 2007
19Timeline: Monday, Feb 5, Morning
• Prior to flight from Bahamas to U.S. felt well with no
complaints for the 3 days prior to flight
• 11:00 AM had dance lesson in preparation for music
video and participation in TrimSpa celebration in
Bahamas
• Planned to shop for furniture in Miami for her
Bahamas home
• Stated intention to marry Howard K. Stern on
February 28, 2007 (per statement of Dr. Eroshevich,
psychiatrist and friend)
• Prior to flight injected left buttock with either vitamin
B12, human growth hormone, or immunoglobulins
(longevity/immune protective medications)
20Timeline: Monday, Feb 5, Early Evening
• Flew from Bahamas to Ft. Lauderdale with Howard K. Stern
and Dr. Eroshevich (psychiatrist and friend)
• Due to pilot’s error, plane landed in Miami at 5:30 PM
• During flight very upbeat and outgoing, however complained
of pain in left buttock when seated
• Complained of cold and severe chills in limo ride to
Seminole Hard Rock Hotel; checked in at 7:30 PM
• Upon arrival to room, temperature of 105 degrees;
refused to go to hospital or let friends call 911
• Placed in ice bath, temperature dropped to 97 degrees
21Timeline: Monday, Feb 5, Late Evening
• Administered
TamiFlu
Cipro (ciprofloxacin), 1000 mg, an antibiotic
Fluids
• Fell asleep at 10:00 PM after a dose of chloral hydrate
(sleeping medication)
Recommended dose is 1 to 2 teaspoons prior to bed
Her routine dose was 2 tablespoons taken as needed
(though she sometimes drank directly from the bottle)
22Timeline: Tuesday, Feb 6
• Next morning, companions noted a “pungent odor”
emanating from Anna Nicole, apparently sweat
soaking the sheets
• Little if any urine production
• Temperature 100 degrees
• Given a bath and oral hydration; pungent odor faded
• Appeared to be doing OK but no appetite; watching TV
• Felt well in early afternoon; took chloral hydrate
and slept for 2 hours
23Timeline: Tuesday, Feb 6, Evening
• Watched TV with Howard K. Stern and Dr. Eroshevich until 11:00 PM
• Took another dose of chloral hydrate (sleeping medication)
• Asked for and received (unknown if she took them):
Soma
(muscle relaxant for painful musculoskeletal conditions)
Klonopin
(anti-seizure and anti-anxiety drug)
Valium
(anti-anxiety drug)
Topamax
(anti-seizure; tranquilizer; used in weight reduction)
24Timeline: Wednesday, Feb 7
• Awake in bed and watching TV at 11:00 AM
• Ate breakfast (egg white omelette with spinach)
• Found naked and confused sitting in dry bathtub in afternoon
• Ordered and ate 2 crabcakes and shrimp for dinner
• Became very upset when her friend/physician
Dr. Eroshevich left town that evening
25Timeline: Wednesday, Feb 7, Late Evening
• Complained of not feeling well and took a bath
• Seen on couch at 10:00 PM watching TV in the living room of
the suite
• Howard K. Stern was in the bedroom in the suite
26Timeline: Thursday, Feb 8
• Took chloral hydrate before falling asleep in early morning
• No longer on couch at 4:00 AM
• About 9:00 AM - may have been seen moving in her bed by
Maurice Brighthaupt (“Big Mo”)-friend/bodyguard/medic
• According to Howard K. Stern, he slept in bed with Miss Smith.
When he woke up some time around 9-10:00 AM, she was
awake. She did not complain of pain but felt very weak and asked
Mr. Stern to help her to the bathroom and back to bed. Mr. Stern
took a shower and left to attend to the purchase of a boat by
Anna. Mr. Stern stated that he did not give Anna any medication
and did not see Anna taking any medication
• At about 12:00 PM, Anna was seen “sleeping” by the wife of
Big Mo, a registered nurse, who was asked to watch Anna by him
• About 1:00 PM the nurse called Big Mo to have him call 911
when Anna was found unresponsive
• The nurse initiated CPR
27Timeline: Thursday, Feb 8
• 1:38 PM – Big Mo returned to room and
continued CPR
• 1:40 PM - Seminole EMS called
• 1:46 PM - EMS arrived in hotel room, administered CPR and
ACLS protocol (including medications such as atropine),
and transported to hospital
• 2:43 PM - EMS arrived at Memorial Regional Hospital
• 2:49 PM - pronounced dead
28Medical Examiner Timeline: Thursday, Feb 8
• Body transported to Medical Examiner’s Office at 4:59 PM
• External examination and collecting of blood and body fluid
samples for:
9 bacteriological and viral cultures
9 cerebrospinal fluid bacteriological cultures
9 intestinal bacteriological and viral cultures
9 DNA sampling
9 Serum for toxicology and chemistries
29Timeline: Friday, Feb 9
• Autopsy performed at 10:36 AM
• Tissues and body fluids taken for microscopic
examination and further toxicological, bacteriological,
serological, and DNA analyses
• Initial assumptions (three choices):
9 Natural death
9 Drug/medication related death
9 Combination of natural and drug related death
• Following interviews of witnesses (Dr. Eroshevich and
Mr. Stern) we learned of the history of buttock pain
and plans were made to re-examine and dissect this
part of the body (not a routine procedure)
30Initial Toxicology Findings
• Received 2/9/07
• Urine drug screen: positive for benzodiazepines (anti-
anxiety/anti-depressant medications)
• Blood and ocular (eye fluid) ethanol: negative
• Vitreous (eye fluid) glucose/electrolytes: non-specific
chloride elevation; no evidence of hyperglycemia;
inconsequential postmortem potassium elevation
31Body Re-Examined 2/12/07
• Incisions made into buttocks and thighs
• Abscesses noted within scar tissue in left buttock
• Extensive scarring of both buttocks
• Linear hemorrhages from skin to abscesses
• Microscopy: abscess, foreign material, and
scarring in buttocks
• Cultures from abscesses grew bacteria: Pseudomonas
luteola and Acinetobacter baumannii
32Additional Toxicology
• Received week of 2/12/07
• Blood drug screen positive for:
9 Topiramate (Topamax; anti-seizure, weight control)
9 Multiple benzodiazepines, including Valium (anti-anxiety),
Klonopin (anticonvulsant) and Ativan (anti-anxiety)
9 Meprobamate (anti-anxiety)
9 Methocarbamol (muscle relaxant)
9 Guaifenesin (phlegm expectorant)
9 Diphenhydramine (anti-histamine)
• All of the above were at therapeutic levels
33Additional Toxicology
• Drugs NOT present in the blood:
9 Methadone
9 cocaine
9 amphetamines (“speed”)
9 THC (marijuana)
9 barbiturates (sleeping pills)
9 morphine and other opiates
9 other illicit drugs
9 cyanide
9 carbon monoxide
9 succinylcholine (paralytic drug)
• All findings confirmed at independent referral labs
34Rare Causes of Death Excluded
• Radiation poisoning
(excluded by Geiger counter testing)
• Ricin and Anthrax poisoning
(excluded by absence of microscopic changes)
• Thallium poisoning
(excluded by symptoms, toxicology,
& microscopic findings)
35Evaluation for Sepsis
• Bacteria were isolated from buttocks abscesses
(described above)
• These abscess bacteria were not present in blood,
probably due to partial sensitivity to the antibiotic Cipro
• Terminal inhalation of oral cavity bacteria into lungs (but no
vomit in airways or lungs)
• Blood, cerebrospinal fluid, urine cultures: no pathogenic
organisms; mild growth of contaminants
• Elevated levels of interleukins 6 and 8 (pro-inflammatory
agents) that indicate an acute inflammatory response,
possibly infection
• No endotoxins detected
36Additional Test Results Received
• Heavy metals: negative
• Insulin and C-peptide: within normal limits
• Cipro (ciprofloxacin) antibiotic level: therapeutic
• Human Growth Hormone: non-contributory
• Serum anti-nuclear antibodies: mildly elevated
but double stranded DNA was negative
• Liver function tests: postmortem artifactual
elevation of liver enzymes
37Stool Cultures
• Negative for Salmonella, Shigella, Campylobacter,
virulent E. Coli species
• Initial viral studies isolated Norwalk virus
by screening assay
• A specific Norwalk virus could not be confirmed by
PCR studies at referral lab or CDC
38Possible Causes of Death
as of 2/19/07
• Sepsis due to deep soft tissue abscesses
due to multiple cutaneous injections
• Viral enteritis
• Likely manner of death: Natural
• No significant contribution by therapeutic
levels of medications
• Additional laboratory tests (microbiological,
toxicological) still pending
39Additional Test Results Received
• Immunoglobulins, complement C3, and serology:
no evidence of immunodeficiency
• Special stains of spleen showed aberrant staining
of B-lymphocytes (may be seen in some
autoimmune states)
• Chloral hydrate blood level: markedly elevated
(toxic to lethal level)
40Chloral Hydrate
• Sedative/hypnotic drug used as sleeping medication
• Available as an elixir (liquid), capsules, suppositories
• Normal liquid dosage: 1-2 teaspoons before bed
• Total daily dosage should not exceed 2 grams (4
teaspoons)
• Side effects: confusion, hallucinations, diarrhea, nausea,
stomach pain, and vomiting
41Chloral Hydrate Toxicity
• Symptoms include extreme weakness, confusion, seizures,
extreme drowsiness, low body temperature, staggering,
changes in heart rate, and breathing problems
• Toxic blood levels: 20 to 240mg/L
• Fatalities reported at blood levels of: > 29mg/L
• Anna Nicole Smith’s blood level: 75mg/L
• May interact with diphenhydramine, anti-anxiety drugs,
sedatives, tranquilizers, alcohol, narcotic pain relievers
42Probable Cause of Death
as of 3/2/07
• Acute combined drug intoxication (chloral hydrate
and therapeutic levels of other drugs)
• Contributory:
Bacterial infection (abscesses)
Mild viral enteritis (intestinal infection)
• Manner of death: ?
• Additional confirmatory testing and consultants
reports pending
43Week of March 5-9, 2007
• Additional test results received:
Non-contributory
• Consultants’ findings discussed:
No surprises
• Interviews with involved parties concluded
• All data synthesized
44Weeks of March 10-23
• Follow-up on additional evidence with potential
impact on manner of death
• Forensic examination of two computers confirmed
intense grieving over Daniel’s death but showed
that her mood had improved, she was generally
enjoying life, and that she was planning on having
another child
• Investigation completed
• Final reports generated
45Final Cause of Death
• PRIMARY:
Acute combined drug intoxication due to
• ingestion of multiple prescription medications
• CONTRIBUTORY:
Bacterial infection (abscesses), Mild viral enteritis,
“Flu”
• HOW INJURY OCCURRED:
Ingested excessive chloral hydrate in combination
with therapeutic levels of other medications
46Manner of Death
• Determined by correlation of autopsy findings,
adjunctive studies, and circumstances leading to
death
• Alternatives:
Homicide
Suicide
Accident
Natural
Undetermined
47Determining Manner of Death in
Cases of Drug Intoxication
• Personality traits
• Recent behavior
• Long term behavior including suicide attempts
• Habits of drug use & abuse
• Levels, types, and lethality of drugs in blood
• Ratio of parent drugs to breakdown products,
(i.e., taking one massive dose or a little too much over time)
• Presence of pills or liquids in stomach
• Evidence of another individual administering drugs to a person
(e.g., forced ingestion, assisted suicide)
48Personality Traits
of Anna Nicole Smith
• Strong personality
• Endured many difficult life experiences
• Solid business woman
• Could be domineering
• Tendency toward histrionic, attention-getting behavior
• Drug-seeking behavior and long history of prescription
drug use including over self-medication
• Obsession with Marilyn Monroe (which was waning
somewhat)
49Possible Future Plans
of Anna Nicole Smith
• Considering having another baby
• Considering marriage in late February 2007
• Planning new business ventures
• Trip to Dubai in March
50The Argument for Accident
51The Argument for
Accident
In most cases of suicide, the victim
ingests a large amount of a drug to
ensure death. In this case, the toxic
blood level of chloral hydrate could be
fatal in and of itself but not necessarily
so. However, it is definitely lethal in
combination with other drugs which
were present at therapeutic levels.
52The Argument for
Accident
In many cases of prescription drug
overdose, multiple drug levels are
significantly elevated.
In this case, all drugs except chloral
hydrate were at therapeutic levels.
53The Argument for
Accident
Reports of suicidal ideation were not
substantiated after mid-October 2006.
Religious upbringing and ideology
prohibit suicide.
54The Argument for
Accident
A near drowning episode in a pool
several months prior to death appears
to have followed an accidental drug
overdose rather than a suicidal act.
Indeed, she thanked the individual who
had resuscitated her rather than being
angry at him.
55The Argument for
Accident
Miss Smith had a long history of
prescription drug use and over-self
medicating. She may have drank a little
too much chloral hydrate to alleviate
symptoms which were secondary to
infection.
56The Argument for
Accident
Miss Smith was likely not aware of the
risks of using multiple drugs while in a
physically vulnerable state consequent
to her infections.
57The Argument for
Accident
Miss Smith had just had a baby and, by
some accounts, was often in good
spirits. There was no evidence of
depression on the way to Florida from
the Bahamas or during her stay in Fort
Lauderdale.
58The Argument for
Accident
There was no suicide note (though these are absent in
many suicides).
No statements expressing suicidal intent after mid-
October 2006 were uncovered.
Suicidal ideation was absent in emails posted after
mid-October 2006.
The investigation suggests she was making definitive
plans for her immediate future.
59The Argument for
Accident
Anna Nicole Smith was a very strong
woman. Having survived the death of
her son, it seems unlikely that she
would choose to end her life because of
her current legal problems.
60The Argument for Suicide
61The Argument for
Suicide
Most close friends state that Miss Smith
was devastated by the death of her son,
Daniel, in September 2006.
She exhibited many symptoms of
clinical depression.
62The Argument for
Suicide
Though it is unclear, Miss Smith may
have threatened to kill herself after
Daniel’s death, and possibly even
attempted to do so by drowning in
October 2006 (though this was more
likely an accident).
63The Argument for
Suicide
Her depression over the loss of her son
occurred shortly after the delivery of her
infant daughter by Caesarean section.
This is a very critical time in which many
women are predisposed to endogenous
depression, so-called postpartum
depression.
64The Argument for
Suicide
Several months prior to her death,
Miss Smith bought 4 plots in a
Bahamian cemetery and had possibly
commissioned a dress for her funeral.
65The Argument for
Suicide
There were several additional
significant life stressors in play at the
time of her death. She was involved in 4
lawsuits, the last of which was filed a
week prior to her death.
66The Argument for
Suicide
By report, Miss Smith did not appear to
be intoxicated when she was last seen
alive. This suggests that she took a
significant dose of chloral hydrate within
a few hours of her death.
67The Argument for
Suicide
The ratio of chloral hydrate metabolites
in the blood suggests ingestion of a
significant quantity of the parent drug in
the hours prior to death (though not
minutes before death).
68The Argument for
Suicide
Miss Smith suffered from soft tissue
abscesses and viral enteritis at the time
of death. Some of the chemical
mediators produced by the body in
response to infection are also elevated
in depression.
69The Argument for
Suicide
Miss Smith suffered from chronic pain
and Hashimoto thyroiditis (chronic
inflammation of the thyroid), both of
which are associated with depression.
70The Argument for
Suicide
Miss Smith had stated a while ago that
she wished to die in the same fashion
as her idol, Marilyn Monroe, who died
by suicide.
Of note, Marilyn Monroe employed
chloral hydrate (in combination with a
barbiturate) in her highly publicized
death.
71The Argument Against Homicide
72The Argument Against
Homicide
Given the level of the chloral hydrate in
Miss Smith’s blood, someone would
have had to either force-fed her or have
her voluntarily ingest a large amount of
liquid chloral hydrate under duress.
73The Argument Against
Homicide
Given the therapeutic levels of the other
drugs in her system, Miss Smith may
have been somewhat impaired but
should have been capable of resisting
attempts at forced feeding.
74The Argument Against
Homicide
There was no oral trauma to suggest
forced feeding.
75The Argument Against
Homicide
Chloral hydrate has a very unpleasant,
harsh taste which should be easily
detectable if an attempt was made to
“slip it” into a beverage.
76The Argument Against
Homicide
There were no other significant injuries.
77The Argument Against
Homicide
There is no evidence at present to
suggest that another individual provided
Miss Smith with drugs to actively assist
her in taking her own life.
78The Argument Against
Homicide
One could speculate that Miss Smith was
cognitively impaired due to her infections
and use of benzodiazepines and that this
rendered her susceptible to homicidal
poisoning. However this would represent
mere speculation that is not supported by
the evidence gathered during this
investigation.
79The Argument Against
Homicide
A police investigation was completed
and found no evidence of foul play.
80The Manner of Death
• Compelling arguments can be made for Accident
• Suicide is less likely
• Homicide is not supported by the police
investigation or our findings
• Natural is not an option since death was caused
by drug intoxication, not a natural disease
process
81Undetermined Manner of Death?
• The classification “Undetermined” is used
when the information pointing to one manner
of death is no more compelling than one or
more other competing manners of death in
thorough consideration of all available
information.
Hazlick et al. A Guide for Manner of Death Classification,
1st Edition, National Association of Medical Examiners
82The Manner of Death in this case is
ACCIDENT.
The evidence for Accident is more
convincing than all other options
(including suicide and homicide).
83Conclusion
PRIMARY CAUSE OF DEATH:
Acute Combined Drug Intoxication (primarily chloral
hydrate with other prescription medications) due to
ingestion of multiple prescription medications
CONTRIBUTORY TO DEATH:
Bacterial Infection (Abscesses), mild viral enteritis, “Flu”
MANNER OF DEATH:
Accident
HOW INJURY OCCURRED:
Ingested excessive chloral hydrate while
taking multiple prescription medications
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